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Injury Report Template – California
Capture timeline, injury details, witnesses, and response actions in one California report.
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Injury Report Template
[Organization / Employer / School / Program Name]
[Address]
[City, State, ZIP]
Phone: [Phone Number]
Email: [Email Address]
1. Incident Snapshot
Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]
Report/Incident ID: [Report/Incident ID]
Primary Location: [Room / Area / Field / Worksite / Street / Other]
Remote/Outdoor or hard-to-access location? [Yes/No]
[If Yes, complete the fields below.]
GPS Coordinates: [GPS Coordinates]
Nearest Cross-Street/Landmark: [Nearest Cross-Street/Landmark]
Access Notes: [Gate code/entry point/boat access/other]
Closest Facility (distance/time): [Closest facility name + distance/time]
Setting Type: [Workplace | School/Childcare | Sports/Recreation | Public Place/Business | Roadway/Vehicle | Home/Residential | Other: ____]
Report Prepared Date: [MM/DD/YYYY]
2. Injured Person Profile
Full Name: [First, Middle, Last]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]
Role: [Employee | Student/Child | Athlete/Participant | Visitor/Customer | Contractor/Vendor | Other: ____]
Home Address:
[Street Address]
[City, State, ZIP]
Phone Number: [Phone Number]
Email Address: [Email Address]
3. Activity at Time of Event
Task/Activity: [Free-text]
Expected/Normal for Setting: [Yes | No: ____]
Tools/Equipment/Items In Use: [Free-text / N/A]
4. Incident Narrative
Who:
[Names/roles; include third parties if any]
What:
[Free-text]
Where:
[Specific spot/route/positioning]
When:
[Sequence and timing]
Why:
[Known facts only; unknown if not established]
How:
[Mechanism; slip/trip/fall/struck/collision/sudden movement/exposure/other]
5. Injury and Symptom Summary
Injury Category: [Head/Face | Neck | Upper Extremity | Torso/Back | Lower Extremity | Multiple | Other: ____]
Injury Subtype: [Free-text]
Side of Body: [Left | Right | Both | Center | Unknown]
Injury Type: [Bruise/Contusion | Cut/Laceration | Abrasion | Sprain/Strain | Suspected Fracture/Dislocation | Burn | Bite/Sting | Head Impact (suspected) | Other: ____]
Visible Signs: [Redness/swelling/bleeding/deformity/limited movement/discoloration/none/other: ____]
Reported Symptoms:
[Free-text; use injured person words where possible]
Pain Score (0-10): [0-10]
Observed Signs: [Dizziness/unsteady | Confusion | Difficulty speaking | Shortness of breath | Pale/sweaty | Loss of consciousness: ____ | Vomiting | Other: ____]
6. Immediate Response and Disposition
Activity Stopped Immediately: [Yes | No: ____]
Responder(s) Name and Role: [List]
On-Site Care Provided: [Cleaned | Bandaged | Ice/cold compress | Pressure | Immobilization | Elevation | Rest/observation | CPR/life support: ____ | Other: ____]
EMS/911 Called: [Yes | No]
Time Called: [HH:MM a.m./p.m. / N/A]
Responding Agency: [Name / N/A]
Transported for Medical Care: [Yes | No | Declined]
Facility Name: [Hospital/Clinic Name / N/A]
Immediate Status: [Returned to normal activity | Returned with restrictions | Sent home | Transported | Other: ____]
7. Timeline Table
Time | Event/Action | Person(s) | Evidence Ref |
[HH:MM] | [Free-text] | [Name/Role] | [Photo # / Video ID / CCTV Cam / Other] |
[HH:MM] | [Free-text] | [Name/Role] | [____] |
[HH:MM] | [Free-text] | [Name/Role] | [____] |
[HH:MM] | [Free-text] | [Name/Role] | [____] |
8. Environment and Conditions
Surface/Walking Area: [Dry | Wet | Uneven | Obstructed | Slippery | Other: ____]
Lighting/Visibility: [Normal | Low | Glare | Night | Other: ____]
Weather/Temperature: [Clear/rain/wind/heat/cold/other: ____ | N/A]
Substances/Contaminants Involved: [Free-text / None]
Equipment Condition Observed: [Normal | Damaged | Missing guard | Out of place | Other: ____ | N/A]
9. Evidence Preservation
Photos Taken: [Yes: Photo IDs ____ | No]
Video/CCTV Available: [Yes: Camera IDs ____ | No | Unknown]
Physical Items Secured: [Yes: Item IDs/location ____ | No | N/A]
Access/Chain of Custody Notes: [Free-text]
Witnesses
Witnesses Present: [Yes | No | Unknown]
Name | Contact | What Observed |
[Witness 1 Name] | [Phone/Email 1] | [Brief description 1] |
[Witness 2 Name] | [Phone/Email 2] | [Brief description 2] |
[Witness 3 Name] | [Phone/Email 3] | [Brief description 3] |
10. Work/Activity Status and Classification
Medical Evaluation Sought After Scene: [Yes | No | Unknown]
Provider/Facility Type: [ER | Urgent Care | Clinic | Personal Doctor | Other: ____ | N/A]
Date of Visit: [MM/DD/YYYY / N/A]
Written Restrictions Provided: [Yes: ____ | No | Unknown]
Days Away/Restricted Duty: [Days away: ____ | Restricted: ____ | Not tracked]
Internal Classification: [First aid only | Medical treatment | Restricted activity | Lost time | Other: ____ | Not determined]
11. Notifications and Sign-Offs
Person(s) Notified: [Parent/Guardian | Supervisor/Manager | HR/Safety | Administrator | Property Owner | Other: ____]
Name and Role: [Name; relationship]
Method: [In person | Phone | Voicemail | Email | Other: ____]
Date/Time: [MM/DD/YYYY - HH:MM a.m./p.m.]
Summary of Communication:
[Free-text]
Follow-Up Owner: [Name, Title]
Target Completion Date: [MM/DD/YYYY]
Planned Follow-Up Actions: [Monitor condition | Request medical note | Inspect area/equipment | Repair/clean/modify | Training/reminder | Policy/procedure update | Other: ____ | None]
Reporting Person Name: [Full Name]
Reporting Person Title/Role: [Title/Relationship]
Reporting Person Signature: [Signature]
Reporting Person Date: [MM/DD/YYYY]
Supervisor/Manager Reviewer: [Name; Title; Signature; Date / N/A]
Safety/HR Reviewer: [Name; Signature; Date / N/A]
Injured Person/Guardian Acknowledgment: [Name; Signature/Declined; Date / N/A]
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Learn more about
Injury Report Template – California
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
California Injury Report Template FAQ
How detailed should the incident narrative be?
Include enough detail that a reviewer who was not present can follow the sequence without guessing. Capture positions, movements, objects or surfaces involved, and what changed right before the injury. Separate what was observed from what was reported by the injured person or others. If a key detail is unknown, state it as unknown rather than filling gaps with assumptions. Using the 5W1H prompts helps keep the narrative focused and reduces later back-and-forth when supervisors or safety reviewers need clarification.
What if the injured person is a visitor or customer rather than an employee?
The same fields still work, but contact and setting details become especially important. Record how the person came to be in the area, what they were doing, and which staff members interacted with them. If the person leaves before providing a full statement, document what was obtained (name, phone, email) and how it was collected. Keep the description factual and consistent, since visitor incidents often trigger follow-up questions about the condition of the area and any immediate actions taken.
Should you document conditions like lighting, floor moisture, or equipment status?
Yes, because scene conditions often explain how an event unfolded and help prevent repeat incidents. Note surface condition, visibility, weather (if relevant), obstructions, and the apparent state of equipment or tools. These details are not about assigning blame; they preserve context that may be difficult to reconstruct later. Even short entries like “wet tile near entrance” or “equipment guard missing at time observed” can support consistent follow-up and corrective action decisions.
Can you update the injury report after it is first submitted?
Many organizations allow updates when new facts appear, such as a later medical visit, delayed symptoms, or newly identified witnesses. If you update the report, record the date of the update and the source of the added information. Avoid rewriting earlier text in a way that hides what was known at the time; instead, add a clearly dated supplement. This approach keeps the record transparent and reduces disputes about when information became available.
What documents or media should be attached to an injury report?
Attachments should support the written record without turning it into a full investigation file. Common items include photos of the scene, references to CCTV camera IDs or clip identifiers, and any relevant logs that can be identified by number (maintenance, cleaning, dispatch, or training records). If the injured person voluntarily provides medical discharge paperwork or restrictions, reference it and store it according to your internal process. When you reference a file, use consistent IDs so it can be retrieved quickly.
When is it useful to include a minute-by-minute timeline?
A timeline is valuable when there are multiple steps, multiple responders, or an unclear gap between the incident and when symptoms were reported. It also helps distinguish incident time, first aid time, EMS call time, and notification times. Timelines reduce confusion in handoffs between supervisor, safety, HR, or risk personnel. If exact times are not available, record them as approximate and note the basis for the estimate, so later reviewers understand the level of precision.
How should restrictions or modified duties be captured?
Record restrictions exactly as communicated, focusing on practical limits rather than medical conclusions. Examples include lifting limits, no sports participation, seated work only, or no driving. If restrictions are not yet known, note that status and assign a follow-up owner to obtain documentation or an update. Capturing restrictions consistently helps supervisors avoid re-exposing the injured person to the same risk and supports scheduling decisions if temporary adjustments are needed. If restrictions are later changed or lifted, add a dated update so reviewers can see the progression over time.
Can AI Lawyer tailor this template to a specific workflow?
AI Lawyer can help you adjust section order, reviewer roles, and evidence fields so the form matches how your organization actually routes incident paperwork. For example, you can add a dedicated case owner line, expand evidence references when CCTV is common, or tighten the narrative prompts for faster completion. The goal is a consistent factual record that still fits your internal process. After customization, accuracy depends on entering facts carefully and keeping updates clearly dated.
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